Systems and methods for assessing and optimizing healthcare administration

ABSTRACT

A comprehensive patient data assessment system and method for use in generating, tracking and analyzing medical data related to healthcare administered by a group of physicians to a specified patient population. The system is operative to track data related to the claims history, case management, pharmacy data, and lab tests/results for each patient treated by each patient&#39;s primary care physician preferably through electronic medical records that are accessible over a computer network. The system is operative to generate data indicative of the utilization of healthcare resources utilized to treat each patient within the patient population, as well as ensure that each primary care physician utilizes appropriate codes for each diagnosis and procedure/test administered to each patient. The system further provides for categorization of patients afflicted with chronic conditions that require high-cost care. The systems are exceptionally effective in conserving medical resources, ensuring uniformity in administering healthcare, and achieving optimal patient outcomes.

CROSS-REFERENCE TO RELATED APPLICATIONS

Not Applicable

STATEMENT RE: FEDERALLY SPONSORED RESEARCH/DEVELOPMENT

Not Applicable

BACKGROUND OF THE INVENTION

The present invention is directed to systems and methods forcomprehensively assessing and optimizing the administration ofhealthcare as rendered by a group of physicians to a specific patientpopulation. More particularly, the present invention comprises systemsand methods that conserve medical resources utilized to care for thepatient population, ensure uniformity in the procedures/tests utilizedto render such care, identify and assess those patients afflicted with achronic condition requiring high-cost healthcare, and provide means tocontinuously monitor and evaluate the quality of healthcare delivered.

Essential to high quality and cost-effective health care is the properdiagnosis of a patient's condition. From a proper diagnosis, theappropriate medical attention utilized to treat the underlyingcondition, whether it be the performance of a medical procedure,laboratory tests and/or prescription of medication, can be determined.To that end, and as is well-known in the art, standard diagnoses codesare extensively utilized pursuant to conventional disease classificationtechniques that provide a quick, well-understood method to documentmedical care administered to a patient. Exemplarily of and perhaps mostwidely utilized of such formats is the International Classification ofDiseases 9^(th) Edition (ICD number 9) three digit codes. Likewise, withrespect to the medical treatment that has been rendered, such proceduresare typically referenced according to Current Procedural Terminology(CPT). Also frequently referenced in connection with the delivery ofhealth care are drug codes (e.g., NDC), other service codes (e.g.,HCPCS), among others.

Notwithstanding such basic principles of medicine, as well as aninfrastructure of coding practices to help facilitate the delivery ofhealth care and documentation of patient treatment, the currentadministration of healthcare in the United States is subject totremendous abuse and is grossly inefficient. In this regard, patients,healthcare providers and healthcare providing institutions oftenencourage wasteful practices that result in needless procedures andtests being performed. Moreover, healthcare providers and healthcareproviding institutions, such as hospitals, clinical laboratories,outpatient and rehabilitation facilities, engage in capricious billingpractices that enable such providers and institutions to charge for amultiplicity of services that may be available under a single clinicalevent that is typically identified by a single CPT code.

Further problematic with such practice is that healthcare providers andhealthcare providing institutions frequently utilize the wrong codes fordiagnosis or otherwise use incorrect or multiple CPT codes to seekreimbursement, whether it be from an insurance company, healthmaintenance organization or government sponsored healthcare program,such as Medicare. In this regard, by failing to follow any type ofuniform healthcare delivery system, and hence uniform coding practicecommensurate therewith, results in overcharges for procedures that havebeen unnecessarily performed, improper diagnosis and duplicative andunnecessary tests and procedures.

In addition to health care providers and institutions, patientsthemselves contribute substantially to the cost and ineffectiveutilization of health care resources. As is well-known, patients can andfrequently do seek unnecessary medical treatment or otherwise attempt toinfluence the judgment of the health care provider by demanding thatunnecessary tests or procedures be performed, that the patients haveaccess to specialists or particular medications, and/or seek in-patientservices in situations where the patient's clinical condition clearlydoes not justify such level of care. Such potential abuses areparticularly likely where patients are allowed the discretion todirectly access specialists, as is typical in several well-known healthcare insurance plans, such as Blue Cross and Blue Shield, which thusbypasses the critical role played by the primary care physician inmaking an initial assessment of a patient's condition and whether thesame truly warrants the attention of a particular specialist, and not tomention the specialist best suited to handle a particular condition.

Such conventional health care practices are particularly wasteful in thecontext of providing healthcare to patients afflicted with a chroniccondition requiring aggressive medical management. Such conditions,known as high-cost chronic conditions, include cancer, cardiovasculardisease, diabetes, HIV, liver disease and pulmonary disease, amongseveral others. To treat such high-cost chronic conditions typicallyinvolves continuous patient treatment, which may take the form of avariety of medical procedures, tests, prescription medicines, and thelike, as well as continuously monitoring the patient's condition to makesure that the underlying chronic condition does not develop to a moreadvance state, develop complications, and/or give rise to furtherrelated medical condition. Current practices, however, are ill suited todynamically treat the progression of disease, and most physicians andhealthcare institutions merely react to the patient's condition asopposed to be proactively involved in and anticipate the potentialfuture needs of the patient. Such lack of responsiveness is typicallyreflected in the coding practices associated with the care delivered tothe patient, which often times can be inaccurate and inappropriate basedupon a general lack of patient history documentation and anticipatedneed to follow up with the patient. As a result of such poor practices,medical costs associated with the treatment of chronic conditions becomeastronomical and almost always beyond the capability of most individualsto pay.

In order to counter such wasteful and abusive practices, attempts havebeen made to implement certain procedures to contain health care costsand conserve the utilization of health care resources. Exemplary of suchattempts include requiring prior authorization and approval by anintermediate entity, such as a health maintenance organization or healthinsurance plan, to the extent a physician seeks to take a specifiedaction, such as perform surgery, order a medical supply or refer thepatient to a specialist. Also utilized are the practices of bundling,whereby a physician is paid a single payment for two or more medicalservices, and capitation whereby a health care provider is paid a setdollar amount as determined by a per member, per month calculation todeliver medical services to a specific patient population (i.e., membersof a health maintenance organization). Still further examples includethe use of preferred provider discounts, which encourage the use bypatients of specific health care providers, and usual and customaryreductions, which impose a reduction in the payment of medical servicesrendered as deemed justified by a health plan or insurance company basedupon what is considered to be the justified value of such services asrendered in a particular geographical area.

Despite such attempts, however, there has yet to be devised any type ofhealth care administration system or method that substantially conservesutilization of health care resources that, as a consequence, candramatically lower the costs associated with providing care to aspecific patient population, especially in connection with the treatmentof patients with high cost chronic conditions. Such attempts havelikewise failed to maintain any degree of consistent quality of healthcare insofar as prior art cost containment practices have been andcontinue to be riddled with “loopholes” with insufficient cost-deterrentmechanisms necessary to conserve and optimally utilize a finite amountof health care resources to treat accurately diagnosed patients.

As a result of the aforementioned abuses and inefficiencies associatedwith the utilization of health care resources, the cost of health carehas and continues to increase substantially while the quality of thehealth care provided has not necessarily improved. As such, there is asubstantial need in the art for a health care administration system andmethod that are operative to effectively and efficiently utilize healthcare resources to administer care to a patient population as compared toconventional practices. There is additionally a need for a healthcareadministration system and method that utilizes a standardized codingpractice that adheres to a standardized diagnosis treatment scheme thatcan be reviewed for accuracy and physician competency. There is stillfurther a need in the art for such a system and method that is generallyeffective in eliminating the wasteful practices associated with theallocation and utilization of health care resources, especially inconnection with the treatment of patients affected with chronicailments, without adversely compromising clinical outcomes or quality ofcare.

BRIEF SUMMARY OF THE INVENTION

The present invention specifically addresses and alleviates theabove-identified deficiencies in the art. In this regard, the presentinvention is directed to a comprehensive medical information andtreatment system that is operative to compile, track and provide meansfor reviewing the administration of healthcare by a group of physiciansand healthcare administration institutions to a specific patientpopulation. In this respect, the present invention is operative toassess the appropriateness of each and every diagnosis, as well as thespecific tests and procedures that have been ordered/rendered by aprimary care physician to specific patients within the patientpopulation. The system specifies, through a uniform coding procedure,each diagnosis and every test/procedure ordered/rendered by eachphysician for each patient such that a comprehensive medical history iscompiled for each patient. The system further tracks each event forwhich medical care was rendered (claims history), the patient's casemanagement, pharmacy information related to all medications prescribedto the patient, and any and all laboratory tests and results therefrom,including the specific dates that such procedures and tests wereperformed and medications prescribed. The compiled data will preferablybe managed as electronic medical records accessible through a computernetwork, and in particular the Internet.

From such compilation of data, an assessment is made according tostandardized care criteria and coding practices whereby a specificphysician can be assessed as to the appropriateness of the diagnosismade, as well as the care he or she has rendered based upon the specificprocedures and tests that were rendered/ordered to the specific patientsunder his of her care. In this regard, it is contemplated that thecompetency and efficiency by which a specific physician practicesmedicine can be adjudged according to the appropriateness of the codingpractices followed by the physician, which will correlate with theproper diagnosis and specific type of procedures and tests administeredto specific patients on specific occasions. Along these lines, it iscontemplated that a number of statistical analyses can be applied inreviewing the electronic medical records that are operative to assesspotentially inappropriate coding practices, which are thus indicative ofwasteful, unnecessary or sub-optimal healthcare.

In addition to the foregoing compilation and assessment of healthcare asadministered by a select group of physicians to a specific patientpopulation, the system further integrates data related to the diagnosisand treatment associated with the care of patients within the patientpopulation afflicted with high-cost chronic conditions, such as cancer,cardiovascular disease, diabetes, pulmonary disease or quadriplegia. Thesystem is further particularly sensitive with respect to the treatmentof high-cost chronic conditions in order to ensure that such chronicconditions have been properly diagnosed, whether further coding(indicative of further specific procedures and tests) may be warranted,whether additional coding is appropriate based upon additional relateddiagnoses based upon the current diagnosis (potential hierarchicalreview), and review to ensure that the treating physician has compliedwith all proper coding procedures indicative of the most cost-effectivemedical management practices coupled with the most favorable patientoutcome.

With regard to those patients that have been properly identified asbeing afflicted with a high-cost chronic condition, the system of thepresent invention is operative to separately compile data relatedthereto to thus enable those patients to be assessed based upon the typeof condition and required long-term treatment necessary to secure themost favorable patient outcome. Additionally, such informationassociated with those members having a high-cost chronic condition canbe utilized to develop cost-effective treatment strategies that may becustom tailored to provide an optimal patient treatment.

In addition to the foregoing, it is further contemplated that by virtueof existing preferably in an electronic medical record format, thesystems and methods of the present invention will be exceptionallyuseful in performing standardized electronic transactions as providedfor in the Health Insurance Portability and Accountability Act (HIPAA)of 1996. In this regard, such transactions, as set forth in HIPAA,expressly include claims, remittance and payment advice, claims status,enrollment and disenrollment in a health plan, premium payments,eligibility inquiries and responses, referral certifications andauthorizations, coordination of benefits, and the like, all of which canbe facilitated through use of the present invention according to astandardized transaction format, which can include the uniform use ofcodes typically associated with conventional billing practices, such asdiagnosis codes mentioned above (i.e., ICDM-9-CM, CPT-4, NDC, andHCPCS).

All of these objectives and more are accomplished by the presentinvention.

BRIEF DESCRIPTION OF THE DRAWINGS

These, as well as other features of the present invention, will becomemore apparent upon reference to the drawings wherein:

FIG. 1 is a flowchart depicting the steps for practicing the presentinvention as it relates to administering and documenting healthcareadministered by primary care physicians to a patient population,including healthcare administered to patients within the patientpopulation afflicted with high-cost chronic conditions.

FIG. 2 is a flowchart depicting information obtained in order togenerate a claims history for each incident medical care is rendered toa patient within the patient population.

FIG. 3 is a flowchart depicting the steps fro obtaining informationrelating to all laboratory tests performed for each patient within thepatient population, as well as the results of such tests.

FIG. 4 is a flowchart depicting information to be obtained in connectionwith pharmacy data/prescription information for each medicationprescribed to each patient within the patient population.

FIG. 5 is a list of high-cost chronic conditions that further includesspecific sub-categories of such high-cost chronic conditions whereineach sub-category diagnosis is assigned a specific HCC code.

FIG. 6 is a listing of the high-cost chronic conditions of FIG. 5 thatare identified as possibly requiring further coding with respect toadditional medical procedures and tests that may be essential to providecare for a patient afflicted with a high-cost chronic condition.

FIG. 7 is a list of medical factors and questions to be taken intoconsideration by a physician when treating a patient properly diagnosedwith cancer.

FIG. 8 is a list of medical factors and questions to be taken intoconsideration by a physician when treating a patient properly diagnosedwith cardiovascular disease.

FIG. 9 is a list of medical factors and questions to be taken intoconsideration by a physician when treating a patient properly diagnosedwith dialysis condition.

FIG. 10 is a list of medical factors and questions to be taken intoconsideration by a physician when treating a patient properly diagnosedwith HIV/opportunistic infections.

FIG. 11 is a listing of potential additional related diagnoses that aphysician must take into consideration when treating a patient havingbeen diagnosed with a specific high-cost chronic condition.

DETAILED DESCRIPTION OF THE INVENTION

The detailed description set forth below is intended as a description ofthe presently preferred embodiment of the invention, and is not intendedto represent the only form in which the present invention may beconstructed or utilized. The description sets forth the functions andsequences of steps for constructing and operating the invention. It isto be understood, however, that the same or equivalent functions andsequences may be accomplished by different embodiments and that they arealso intended to be encompassed within the scope of the invention.

Referring now to FIG. 1, there is schematically illustrated the varioussteps by which the system and method of the present invention 10 operateto generate data related to the delivery of healthcare to a patientpopulation and how such delivery of healthcare can be optimized. To thatend, it is contemplated that the present invention will be utilizedexclusively by healthcare providers, which includes physicians,hospitals, medical groups, healthcare plans, health maintenanceorganizations, or any entity that provides healthcare to a patientpopulation.

To create such framework, a patient population is first established 102to which healthcare will be provided. To that end, it is contemplatedthat the identification of the patient population may take any of avariety of forms well-known in the art, including the teachings ofApplicant's co-pending patent applications U.S. patent application Ser.No. 10/615,640, filed Jun. 8, 2003 entitled HEALTHCARE ADMINISTRATIONMETHOD and U.S. patent application Ser. No. 10/679,178 entitledHEALTHCARE ADMINISTRATION METHOD HAVING QUALITY ASSURANCE, filed on Oct.3, 2003, each of which are expressly incorporated herein by reference.

To care for such patient population, there is further provided a networkor infrastructure of healthcare providers and healthcare providinginstitutions that will preferably comprise an integrated medicaldelivery system consisting of physicians and in-patient and out-patientfacilities capable of comprehensively delivering medical treatment tothose patients within the patient population. In this respect, and asper the teachings of Applicant's aforementioned pending patentapplications, the present invention relies upon a procedural frameworkwhereby primary care physicians are responsible for the initialassessment, diagnosis and treatment of those patients within the patientpopulation seeking treatment. Moreover, for reasons discussed more fullybelow, such primary care physicians (PCP's) are further obligated toclosely adhere to a strict coding procedure that accurately andefficiently standardizes medical diagnosis and, based upon suchdiagnosis, helps dictate what medical services, both short term and,where applicable, long term, are to be rendered in relation to aspecific patient's condition.

To that end, and in order to deliver healthcare to patients within thepatient population, primary care physicians (PCP's) will be assigned topatients within the patient population via 104 and will be primarilyresponsible for administering care thereto. With respect to sucharrangements, it is contemplated that any of a variety of well-knowntechniques and healthcare practices known in the art can be utilized,such as those established by insurance carriers, health maintenanceorganizations, and the like are made available to patients within thepatient population to access for treatment. In this respect, it iscontemplated that conventional office-based appointments/doctors visitswill be coordinated between patients in the patient population and theirrespective PCP's according to conventional practice.

Key to the practice of the present invention occurs in step 106, whichis implemented every time a PCP treats a patient within the patientpopulation. According to such step, significant documentation will beobtained in relation to the nature of medical care administered to apatient by a PCP, or other specialist as may be required, as discussedmore fully below in relation to FIGS. 2-4. To that end, it is expresslycontemplated that the systems and methods of the present invention willincorporate the use of electronic medical records that are operative tofacilitate the input, storage, retrieval, transfer and review of medicalinformation to other entities involved in the delivery of healthcare topatients within the patient population, including hospitals, in-patientand out-patient facilities, labs, insurance carriers, physiciansoffices, and the like. Exemplary of certain lesser-preferred formatsoperative to generate electronic medical records include medical recordsoftware produced by American Medical Software of Edwardsville, Ill.;Smart Doctor EMR, produced by Intelligent Medical Systems, Inc. ofAlpine, Tex.; SOAPware EMR Software produced by Docs, Inc. ofSpringdale, Ariz.; and EMR Medical Software produced by Expert SystemApplications, Inc. of Solon, Ohio.

In a preferred embodiment, the medical records generated electronicallythrough the preferred practice of the present invention will beaccessible over the Internet or through secure intranet computernetworks well-known to those skilled in the art. Exemplary of amost-preferred implementation of the systems and methods of the presentinvention include proprietary medical data management the websitehttp://www.hmshcc.com operated by Heritage Medical Systems of Reseda,Calif. As will be readily understood by those skilled in the art, byproviding a web-based system greatly facilitates access to medicalrecords, as well as is operative to provide secure means by which suchdata can be generated, stored, retrieved and reviewed.

Given the electronic medical record format by which the delivery ofhealthcare will be documented according to step 106, there will furtherbe implemented a coding practice associated with the delivery of suchhealthcare. The documentation and coding practice will preferably beconsistent with the schematics as set forth in FIGS. 2-4.

With reference to FIG. 2, there is shown a first area of data to becollected in connection with the treatment of a specific patient withinthe patient population by the patient's PCP. Such information isdirected to the creation and documentation of a claims history. To thatend, for each incident for which medical care is rendered, there will bedocumented the identity of the treating physician 200 and a specialtydescription of that physician, and whether or not the same is thepatient's PCP or otherwise a medical specialist. A diagnosis willfurther be identified in 202 that, for reasons discussed more fullybelow, will be consistent with a conventional coding practice, such asICD-9-CM, well-known to those skilled in the art. Of substantialsignificance, and likewise discussed more fully below in connection withstep 108, is whether or not the diagnosis involves a high-cost chroniccondition determined in step 204, which if accurate, is operative totrigger a comprehensive on-going medical assessment that ensures thatall aspects of the patient's condition are adequately reviewed andconsidered when implementing treatment.

In response to the identified diagnosis made in 202, documentation isfurther obtained with respect to the specific medical procedure that wasrendered to treat such condition in step 206, as well as where suchservices were rendered, whether it be a hospital, in-patient orout-patient facility, and the date the medical services were rendered.To facilitate the input of such information, it is contemplated that thedescription of the medical procedures as performed may be consistentwith the use of conventional CPT codes, such as CPT-4 and other servicecodes, such as HCPCS, among others. Key with the identification of thedescription of the medical procedure/services rendered will be anassessment as to how the same were effective and appropriate in treatingthe condition diagnosed.

In addition to the claims history information generated as part of theimplementation of the documentation and coding practice of step 106 ofFIG. 1 and sub-steps 200-206 of FIG. 2, is the documentation of all labresults for each service provided to each patient. With respect to thedocumentation of such information, there is depicted in FIG. 3 theinformation that should necessarily be obtained in connection with anytests ordered in connection with the treatment of a specific patientwithin the patient population. As illustrated, the physician orderingthe specific tests should be documented 300, along with the physician'sdiagnosis warranting the specific tests 302. To that end, it iscontemplated that standardized diagnoses and procedure/service codes canbe utilized. It is further preferred that a description of the lab testbe provided 304 as well as the results of the prescribed tests 306.Where applicable, to the extent information regarding specific tests hassome type of clinically meaningful outcome, the same should be indicatedin 308. It is further contemplated that the dates of such tests arerendered likewise be documented as part of step 308.

As a further component of the documentation and coding practiceimplemented in connection with the delivery of healthcare set forth instep 106 of FIG. 1, there is shown in FIG. 4 the documentation to beobtained in connection with any relevant pharmacy data. As illustrated,such information gathering includes the steps of identifying theprescribing physician 400, identifying the medication prescribed 402,including the strength/dosage thereof. With respect to the latter, it iscontemplated that the medication will be identified by name, dailydosage (when applicable), and the strength of the medication prescribed(e.g., famotidine 40 mg hs). Further pharmacy data to be documentedinclude the quantity, such as the number of tablets prescribed to aspecific patient and, in step 404, the date when such prescription isfilled.

Comprehensively documenting all such information as part of the deliveryof healthcare by PCP's to the patients they treat within the patientpopulation will be operative to not only generate an extremelycomprehensive, easily accessible, and easily updatable electronicmedical record system, but will further enable the accuracy of thediagnoses to be assessed, as well as the appropriateness of thehealthcare administered in relation thereto. To that end, and beforediscussing specific procedures followed in connection with the properdiagnosis of a patient having a chronic condition, the systems andmethods of the present invention integrate a review step 110 that isoperative to enable overseeing physicians, healthcare administrators,hospitalists or other knowledgeable individuals having a thoroughunderstanding of the administration of healthcare to determine whether asubmitted diagnosis and procedure/test rendered in response thereto isappropriate based upon a multiplicity of factors. In this regard, it isexpressly contemplated that those practices disclosed and claimed inconnection with Applicant's co-pending U.S. patent application Ser. No.10/615,640 can be implemented to ensure that each of the PCP'sadministering healthcare to patients within the patient population arefollowing a standardized protocol that strictly adheres to the deliveryof quality, cost-effective healthcare.

As a further means of reviewing the PCP's performance in accuratelydiagnosing each specific condition for which each specific patient istreated, the systems and methods of the present invention may furtherincorporate the methodology of U.S. patent application Ser. No.10/679,178, which incorporates a reference for standardized performancemeasures for rendering healthcare. Exemplary of such standards expresslyinclude the National Committee for Quality Assurance's (NCQA) HealthplanEmployer Data and Information Set (HEDIS), which is well-known andrecognized in the art as a recognized standard for quality of healthcareand service that healthcare plans should attempt to provide to theirmembers. Accordingly, such review of diagnosis and treatment, coupledwith standardized treatment practices recognized in the art (as may bepromulgated by consumer groups, government agencies, or healthcareadministration agencies, including HEDIS standards discussed above),enables healthcare to be administered to the patients within the patientpopulation according to recognized standards of care that can becontinuously reviewed and updated.

To that end, the systems and methods of the present inventionincorporate a further component, namely, component 112 shown in FIG. 1,that enables all of the diagnoses, treatment, lab tests, andprescription information outlined above to be compiled, assessed, andreviewed to ensure that the best medical management practices arefollowed, as well as how the delivery of healthcare can be administeredas efficiently and cost-effectively as possible. In this respect, it iscontemplated that a number of statistical techniques can be deployed todetermine the rate of error by which one of more physicians improperlydiagnoses a specific condition, perform an inappropriate procedure inresponse to a diagnosed condition, order wrong or unnecessary tests inresponse to a diagnosed condition, and/or prescribe medication that iseither inappropriate, sub-therapeutic or improperly indicated to treat aspecific condition. Along these lines, it is contemplated that all ofthe PCP's administering healthcare to the patient population can becontinually reviewed and assessed for their performance to thus ensurethat not only are the most cost-effective healthcare practices are beingutilized, but to also improve physician judgment, eliminate wastefulpractices, and that most cost-effective medical treatment is delivered.In this respect, it is expressly contemplated that the systems andmethods of the present invention will achieve the dual purpose ofconserving medical resources while at the same time improving thedelivery of healthcare by ensuring that proper diagnosis, and henceappropriate procedures, tests, and medications prescribed in responsethereto, are administered with little to no waste of resources.

In addition to the implementation of procedures to document and reviewthe delivery of health care administered to a patient population,particularly with respect to the diagnosis of specific medicalconditions and the procedures/tests performed in response thereto, thesystems and methods of the present invention are particularly wellsuited for the cost-effective management of those patents within thepatient population afflicted with high-cost chronic conditions. Asdiscussed above in relation to FIGS. 1 and 2, as part of the diagnosisand treatment of each patient, each physician will identify, whereappropriate, whether such patient is being treated for a high costchronic condition, as identified in step 108 of FIGS. 1 and 204 of FIG.2. Essentially, whether or not a patient is afflicted with a high-costchronic condition will be determined by conventional medical evaluationand will encompass those specific chronic conditions specified in FIG.5.

Presently, the present invention contemplates that high-cost chronicconditions can be identified as falling within at least eight (8)separate categories, namely cancer, cardiovascular disease, diabetes,dialysis condition, HIV/opportunistic infections, liver disease,pulmonary disease and quadriplegia/extensive paralysis. As furtherillustrated in FIG. 5, within each category of high-cost chronicconditions are specific medical conditions that are identified by aseparate code. For example, for cancer, there are identified four (4)separate cancerous conditions, each of which having its own high-costchronic condition (HCC) code. As shown, breast, prostate, colorectalcancers are identified as HCC 10; lung, upper digestive track and othersever cancers are identified as HCC 8; lymphatic, head and neck, braincancers are identified as HCC 9; and metastatic cancer and acuteleukemia are identified as HCC 7. Similar subcategories with their owndedicated HCC codes are further provided for each of the eightconditions. In this respect, it should be recognized that the HCC codesare exemplary of those that can be utilized in the coding practicesutilized in the practice of the present invention. Such coding practiceis significant insofar as the same not only reflect what should be themost accurate diagnosis of a patient, but in the case of a high-costchronic condition, proper diagnosis is imperative to insure that thebest, most comprehensive and cost-effective treatment can be deliveredto the patient and that all relevant factors and disease progression aretaken into consideration.

As part of such process, the initial step begins with confirming that apatient is in fact being treated for a high-cost chronic condition in114. Such diagnosis is reviewed as part of such step to ensure that thediagnosis continues to accurately reflect the condition of the patient.Advantageously, such continuous review of the diagnosis ensures that thepatient's condition is accurately characterized with the mostappropriate treatment being utilized, as opposed to conventionalwasteful practices where a chronic condition, once diagnosed, is treatedindefinitely in a static, non-dynamic fashion which often time neglectsto take into consideration related medical diagnosis and can result insuboptimal and even harmful care.

In addition to continuously reviewing the appropriateness of thehigh-cost chronic condition diagnosis, further assessment is made instep 116 with respect to any type of insurance claims submissions. As iswell-known in the art, health care benefits are typically treated on anannual basis, with deductibles for which the patient is responsible forpaying becoming due on the first of the calendar year. By virtue of thefact that such high-cost chronic conditions often times afflict patientsfor years, there is advantageously built into the systems and methods ofthe present invention procedures by which medical records arecontinuously updated so that to the extent insurance benefits arerenewed periodically, such as a calendar year basis, all applicableinformation is necessary to insure ongoing coverage, benefits, and thelike will be updated as part of step 116 such that a continuum of carecannot only be provided to the patient, but that the applicable benefitsand coverage attendant thereto can be administratively tracked andreviewed. As is well-known in the art, to the extent such information isnot timely updated, substantial administrative problems can occur whichcan require resubmission of claims information and potentially triggerthe loss of certain benefits or otherwise trigger an obligation for thepatient to pay higher deductibles, medical costs, and the like, whichthe patient would not otherwise be obligated to do but for accurate andtimely diagnosis information that is properly updated.

In order to provide the most comprehensive care for such patientsafflicted with a high-cost chronic condition, the present inventionfurther takes into account potential medical complications associatedwith each specific high-cost chronic condition that enables the treatingphysicians to anticipate such potential complications and relateddiagnoses. As illustrated in step 118 of FIG. 1, there is integratedwithin the systems and methods of the present invention an on-goingpatient assessment whereby specific chronic conditions are reviewed todetermine if further coding is required. In this respect, and asdepicted in FIG. 6, a listing of the various chronic conditions will beprovided and, preferably through a link provided as part of theelectronic medical records for each patient, a series of pertinentclinical questions specific for each condition that must be taken intoaccount by the treating physician in order to properly assess whether ornot further coding is required for a given patient. For example, to theextent the patient has been diagnosed with cancer, when updating theelectronic medical records for such patient the physician will beprovided a quick reference to those questions identified in FIG. 7 thatwill direct the treating physician to continuously evaluate and assessthe patient's condition and ultimately direct the physician to followthe proper medical protocol, through the coding practices referred toherein, to ensure that not only are further medical procedures and testwarranted, but that the correct procedures and tests are prescribed andcarried out in a timely manner to provide the best patient carepossible. For example, in FIG. 7, to the extent a patient has beendiagnosed with cancer, the treating physician will necessarily beprompted to review each of the questions identified, such as whether ornot the patient has been actively managed for malignant neoplasms andwhether the medical records for such patient contained documentation ofactive treatment for pulmonary or disseminated micro bacteria, amongothers. To the extent a patient does have a specific type of condition,such as a malignant neoplasm of the prostate or if the patient hasmalignant breast cancer, additional coding may be required to provideadequate care to the patient. Advantageously, by utilizing the extremelycomprehensive collection of data discussed above enables the patient'scondition to be thoroughly assessed to not only provide the mostpractical health care but to also substantially minimize, if noteliminate, potential liability for a misdiagnosis and improper patientdocumentation.

Referring now to FIGS. 8-10, there is illustrated those clinicalquestions that must be asked for those patients properly diagnosed ofother types of high-cost chronic conditions. In FIG. 8, there isillustrated the questions linked to cardiovascular disease which everyphysician must review for each patient properly diagnosed with suchcondition. As illustrated, the treating physician must take intoconsideration whether the patient has prior history of cardiopulmonarydisorder predisposing to current cardiac issues and whether the patientmeets clinical criteria for cardiomyopathy, among other considerations.Also, to the extent atrial or ventricular arrhythmia is diagnosed,specific coding is essential to ensure that the appropriate on-goingmedical diagnosis, treatment and tests are prescribed.

FIG. 9 represents those considerations that must be made to the extentthe patient is properly diagnosed with a dialysis condition. Asillustrated, physicians must take into consideration whether or not thepatient was receiving accurate treatment for chronic renal failure,chronic uremia, and other conditions while the patient had previouslybeen treated. Likewise, FIG. 10 depicts those questions that thephysician is directed to and is to take into consideration to the extentthat the patient has been properly diagnosed with either HIV or anopportunistic infection. For example, a treating physician mustnecessarily review and determine whether or not the patient haspreviously been treated for candidal pneumonia, aspergillous species, orother types of infections attendant to the underlying treatment of thepatient's chronic condition.

With respect to the further coding that must be taken into considerationas illustrated in FIGS. 6-10, it will be understood by those skilled inthe art that the specific questions and further medical assessment thatthe physician will be prompted to take into consideration will becontinuously updated as improvements are made in medicine regardingpatient diagnosis and treatment. It is likewise contemplated thatadditional high-cost chronic conditions may be added to those identifiedin FIG. 6 and that for each such additional chronic condition, a subsetof the questions and clinical treatment considerations will beidentified using known, objective diagnostic standards that will beagreed upon by the medical community as providing a standard that alltreating physicians should follow according to best patient managementpractices. Accordingly, the specific questions and considerations setforth in FIGS. 7-10 are merely illustrative of the furtherconsiderations that are made with present best medical managementpractices.

As a further consideration to be documented as part of theadministration of care to patients with high-cost chronic conditions,the treating physician will further identify whether or not the patientafflicted with the high-cost chronic condition is adjudged to haveeither a low, medium or high risk as part of step 118. Along theselines, and as is well-known to those skilled in the art, the severity ofa given condition can be readily assessed, and the present inventiontakes such risk into consideration so that the aggressiveness of medicaltreatment can be proportionately tailored to address the same. Theassignment of risk will be periodically updated and reviewed foraccuracy. To the extent a patient is properly identified as being ahigher risk patient, it will be understood that more aggressive measuresmay be taken should a favorable patient outcome be reasonablyanticipated. On the other hand, designating such a patient as high risk,depending on the circumstances, may warrant that only palliativemeasures be taken to thus not only conserve medical resources, but toalso treat the patient as realistically as practical.

In addition to continuous review of diagnosis, risk assessment, claimsupdating and review of the patients' conditions to determine whether ornot further coding is appropriate, the present invention furtherincludes a component, identified as 120 of FIG. 1, that involvesdetermining whether or not a given high-cost chronic conditionprogresses to a further stage requiring additional diagnosis.Specifically, patients that have been properly diagnosed with ahigh-cost chronic condition will further be continuously reviewed forpotential additional related diagnosis. As explained in connection withFIGS. 5 and 11, there is illustrated the specific high-cost chronicconditions by specific HCC codes in FIG. 5 and how those patientsdiagnosed with such specific conditions will be reassessed by thetreating physicians to determine whether or not an additional relateddiagnosis identified in FIG. 11 must also be made. For example, patientsdiagnosed with a high-cost chronic condition code HCC 8, such as lungcancer for example, will further be reviewed by the treating physicianto determine whether or not the patient should further be diagnosed withHCC 7, namely metastatic cancer. Similarly, patients diagnosed withdiabetes with acute complications, HCC 17, will be reviewed to determinewhether or not a diagnosis of diabetes with neurologic manifestation HCC16 or diabetes with peripheral circulatory manifestation HCC 15 arejustified as additional related diagnoses. Such review will becontinuously documented as part of the patient's medical records

The review for potential additional related diagnoses will be consistentwith objective, standardized medical management practices, and maychange from time to time as such medical practices change in the art.With respect to the additional related diagnosis identified in FIG. 11,it will thus be understood that the same may change or become modifiedover time as such medical practices dictate. Advantageously, by takingsuch related diagnoses into account, the practices of the presentinvention enable a patient's condition to be dynamically treated,especially if the disease progresses on to the related conditionsidentified. For example, patients with chronic hepatitis, HCC 27 orcirrhosis of the liver HCC 26, will be continuously monitored todetermine whether or not the patient ultimately progresses to end-stageliver disease HCC 25. All medically appropriate procedures and tests canthus accordingly be assigned to such patient as the patient's diseaseevolves, which in turn allows for the most applicable medical treatmentin conservation of medical resources.

The systems and methods of the present invention further include, aspart of such comprehensive diagnosis, treatment, review anddocumentation of patients with high-cost chronic conditions, a reviewcomponent 122 that, per the practices discussed above, ensure that thetreating physicians are delivering the most appropriate,objectively-reasonable health care as may be reviewed by knowledgeablehospitalists, administrators, health care workers, and the like. Alongthese lines, such review component plays an important role in themanagement of high-cost chronic conditions insofar as those patientsproperly diagnosed with high-cost chronic conditions often times utilizevastly more medical resources and require substantially greater care forlonger periods of time than the vast majority of the patients within thepatient population. Accordingly, one of the major objectives of thepresent invention is to provide a tool operative to contain costs indelivering health care to a patient population and by integrating suchreview step allows not only for the best standard of care to beadministered utilizing objective criteria, but also be delivered inextremely efficient and cost effective manner.

To that end, the present invention, by focusing on delivering such costeffective health care for the treatment of those patients afflicted witha high-cost chronic condition, enables those patients to be readilyidentified in optional step 124 to define a subpopulation whoseinformation can be readily accessed, reviewed and scrutinized todetermine whether or not the best most efficient medical practices arebeing followed. Identifying such patient population can be of additionaluse in assessing the epidemiology and etiology of specific diseases andmedical conditions.

Additional modifications and improvements of the present invention willbe apparent to those of ordinary skill in the art. Along these lines,the systems and methods of the present invention can be implemented aspart of virtually any health care delivery system, including anyconventional public or private system, such as a health maintenanceorganization, health plan or government sponsored program, that isresponsible for overseeing the utilization of health care resources ofan integrated delivery system to administer health care to a patientpopulation. If implemented correctly, the systems and methods of thepresent invention can optimally administer and substantially conservethe utilization of health care resources to thus enable high-quality andobjectively verifiable health care to be delivered while at the sametime enabling cost-effective services to be rendered. Indeed, it iscontemplated that the health care administration systems and methods ofthe present invention can and will serve as a model from which existinghealth care administration systems can and emulate to not only conserveresources, but where applicable, substantially increase profitabilityand improve patient outcomes.

Moreover, the system of the present invention, while advantageouslypreserving the interests of privacy and security related information,may further be useful in facilitating standardized electronictransactions, consistent with the mandate of HIPAA, as well ascollecting information useful for research. In this respect, the systemof the present invention will be operative to obtain information relatedto a specific medical practice, hospital, or type of care provided in ageneral area, which may be extremely useful in predicting trends andanticipating future healthcare needs. In this regard, informationrelated to hospital admissions, type and nature of medical procedures orservices rendered by a specific medical practitioner or medical group,type and volume of prescription medications that are prescribed by aspecific physician or medical group, and information related generallyto the diagnosis and clinical evaluation made by a practitioner ormedical group can be compiled through the system of the presentinvention and useful in assessing the epidemiology and etiology of aspecific disease or abnormal condition. Furthermore, in certain limitedapplications, the data created by the system of present invention may beuseful as marketing data which can be utilized to determine the practicecharacteristics of a specific practitioner or health group. Exemplary ofthe latter includes prescribing habits, particularly with respect tovolume and types of medication prescribed by a given practitioner, whichis extremely useful as marketing data for determining saleseffectiveness, market share, and trends in medical management practices.

Accordingly, the particular combination of parts and steps described andillustrated herein will be understood to represent only certainembodiments of the present invention, and are not intended to serve aslimitations of alternative systems and methods falling within the scopeof the present invention.

1. A method of administering healthcare comprising the steps: a.identifying a patient population to which healthcare is administered; b.identifying a group of physicians responsible for administering care tosaid patient population identified in step a; c. receiving a requestfrom a patient within said patient population for medical services to berendered by a respective one of said physicians identified in step b; d.implementing a coding practice in response to said request made in stepc wherein said physician requested to render medical services inresponse to said request inputs in to an electronic medical recordssystem a diagnosis code indicative of the physician's diagnosis of thepatient's condition and a code indicative of the medical servicesrendered to treat the patient's condition; e. assessing said diagnosiscode input in step d for accuracy and appropriateness of the code inputin step d for the prescribed medical services tendered; and f.statistically tracking any incidence of inaccurate diagnosis orinappropriate medical services rendered in step e.
 2. The method ofclaim 1 wherein in step d, additional medical information is input intosaid electronic medical record, said additional information comprisingthe identity of the patient, the identity of the physician, the facilitywhere medical services were rendered and the date said medical serviceswere rendered.
 3. The method of claim 2 wherein in step d, said medicalinformation input into said electronic medical records further comprisesinformation identifying any laboratory tests ordered in connection withthe treatment of said patient, results of such laboratory tests, and thedate such arbitrary tests were ordered.
 4. The method of claim 2 whereinin step d, said medical information input into said electronic medicalrecords further comprises pharmacy data related to any prescriptionmedications prescribed to said patient in connection with the medicalservices rendered by said physician, said pharmacy data comprisingidentifying the prescribing physician, identifying the medicationprescribed, indicating the strength of the medication prescribed,indicating the dosage of the medication prescribed, identifying thequantity of medication prescribed, and indicating the date suchmedication was prescribed.
 5. The method of claim 1 wherein said methodfurther comprises repeating steps a-f such that electronic medicalrecords are generated for each patient within the patient populationcorresponding to each time each patient has requested medical servicesfrom physicians specified within the group of physicians.
 6. The methodof claim 5 further comprising the step of periodically reviewing andevaluating said electronic medical records to determine the accuracy ofdiagnoses and utilization of healthcare resources as administered bysaid physicians amongst said patients within the patient population. 7.The method of claim 1 wherein in step b, said group of physicianscomprises primary care physicians.
 8. The method of claim 1 wherein instep d, said coding practice further comprises identifying a high-costchronic condition code to the extent said patient seeking medicalservices is diagnosed with a high-cost chronic condition.
 9. The methodof claim 8 wherein said high-cost chronic condition is selected from thegroup of conditions consisting of cancer, cardiovascular disease,diabetes, dialysis condition, HIV/opportunistic infection, liverdisease, pulmonary disease and quadriplegia/extensive paralysis.
 10. Themethod of claim 9 wherein when said patient is diagnosed with ahigh-cost chronic condition, step e further comprises reviewing andconfirming said diagnosis of said high-cost chronic condition,periodically reviewing said patient's condition to determine whetherfurther coding is required, and reviewing said patient's condition todetermine whether said patient needs to be diagnosed as having a relatedmedical condition.
 11. The method of claim 10 wherein in step d, saidmedical treatment administered to said patient conforms to astandardized criteria of care.
 12. The method of claim 11 wherein saidstandardized criteria of care substantially conforms to criteriaestablished by the National Committee for Quality Assurance.
 13. Themethod of claim 12 wherein in step d, said electronic medical recordsare accessible over a computer network.
 14. The method of claim 13wherein said electronic medical records are accessible over theInternet.
 15. The method of claim 12 wherein in step e, a standardizedevaluation is implemented to ensure that patients afflicted with ahigh-cost chronic condition are continuously evaluated according to astandardized medical criteria consisting of clinical questions regardingthe progression of the patient's disease and a review of the patient'smedical records.
 16. A system for facilitating the administration ofhealthcare comprising: a. a computer network operative to receive,generate, store, retrieve and transmit data; b. an electronic medicalrecords system operative to receive, generate, store, retrieve andtransmit medical data indicative of medical diagnoses and servicesrendered by individual physicians to individual patients, saidelectronic medical records system being operatively interfaced with saidcomputer network; c. a standardized criteria of care integrated withinsaid electronic medical records system for comparing a standardizedcriteria of care to care rendered by said physicians to said patients asdocumented by said electronic medical records; and d. a review authorityfor comparing said differences in said standardized criteria of care andsaid care identified in said electronic medical records.
 17. The systemof claim 16 wherein said electronic medical records system is operativeto receive coding information corresponding to diagnostic informationand coding information corresponding to medical treatment information asrendered by said individual physicians to said individual patients. 18.The system of claim 19 wherein said electronic medical records system isfurther operative to receive data indicative of the diagnosis andtreatment of patients afflicted with a high-cost chronic condition andsaid standardized criteria of care integrated within said electronicmedical records system is operative to provide an indication to thephysicians treating said patients with said high-cost chronic conditionto determine whether treatment of said patient requires further codingand whether said patient requires diagnosis of a related medicalcondition.